ATI RN Level 2 Practice A V4 (2026–2027 Updated) | Concept-Based Assessment | Comprehensive Q&A with Rationales | 100% Accurate

ATI RN Level 2 Practice A V4 (2026–2027 Updated) | Concept-Based Assessment | Comprehensive Q&A with Rationales | 100% Accurate Q. 1200 - Client c/o abd pain, nausea & low grade fever for several days. Reports oral intake has been minimal for the past 24 hrs. Grimacing & appears uncomfortable. BS clear bilaterally. Abd round, slightly distended w/increased high-pitched BS noted in UQ of abd. No BS in LQ. Negative Blumberg sign. ANSWER 1600- vomited 400 mgl of orange-brown emesis 1230 - WBC 9500 (5k-10k) Hgb 17 (14-18) Hct 50% (42-52%) Serum amylase 70 (30-220) Serum lipase 130 ( 0-160) Glucose 100 (74-106) T 100.4 F HR 108 RR 20 BP 116/64 O2 Sat 95% on RA Abd pain 8/10 Q. What condition is client most likely experiencing? 2 actions nurse should take to address condition & 2 parameters nurse should monitor to assess client's progress? abd pain, low grade fever, n/v -- ANSWER Condition: small bowel resection Nrsg Actions: prepare to insert NG tube & Admin IV flds Parameters to Monitor: Abd distention & Serum K+ & Na+ levels Q. Client presents to ED c/o chest pain - "I think I'm having a heart attack." Appears anxious, mucous membranes are pint & moist. Peripheral pulses are 2+ and equal. S1, S2 auscultated, reg rate, no murmur noted. BS clear bilat. Abd is round, soft, non-distended, no-tender. Multiple striae present. Diaphoretic, color consistent w/ genetic background. 2+ pedal edema. Pain 10/10 to mid-epigastric area. Pain worse when bending over or lying down. Non productive cough. Pain 2/10 3 hrs 15 mins later. ECG: normal sinus rhythm. Troponin T 0.1 ng/mL ( 0.1), repeat Troponin T 0.1 ng/mL. VS 151/92-99F-85-18-95%-BMI 35.1; repeat 1 hr later BP 144/%. Which finding require follow up? ANSWER CV: 2+ pedal edema Resp: non-prod cough GI: epigastric pain 10/10; pain worse w/bending over or lying down Skin: diaphoretic findings assoc w/GERD post-op day 1 - s/p bowel resection post-op day 2 - skin warm & T 101.8F blood culture - enterococcus faecalis - not sensitive to Vancomycin abx Vanco 1 gm IV q12h VS WNL Tylenol 650 mg q6h prn T 100.4F Q. Nursing action to take? SATA a) contact precautions b) request prescription for alternative abx c) wear a mask when working w/i 3 ft of client d) limit movement of client outside of room e) place in a negative pressure room ANSWER a, b, d Q. 8 mth old infant at pediatrician office. 2 days ago seen at clinic w/irritability and decreased PO intake. Physical Exam: ANSWER Gen: awake/alert, lg amts of drool noted HEENT: anterior fontanel soft/flat, bilat tympanic membrane pearly gray, rhinorrhea present, dryness of nasal passages noted CV: S1, S2 - cap refills 3 secs Abd: soft/rounded, legs drawn up w/palpation Q. Which assessment finding is consistent with Otitis Media or Acute Streptococcal Pharyngitis? ANSWER Temp & Lymphadenopathy & increased resp rate = OM & Strep pharyngitis Abd pain = Strep pharyngitis Erythematous & edematous tympanic membranes = OM Q. Nurse is reviewing medical records of client who has peptic ulcer. Which of the following findings is a priority to report to the provider? ANSWER melena stools Hgb 7.6 Wt gain of 3 lb in 2 weeks Dyspepsia during the day Hbg 7.6 = low (indicates ulcer is bleeding) melena stools are expected finding of PU wt is expected finding d/t indigestion & urge to eat to decrease dyspepsia - expected finding of PU Q. Nurse is admitting client w/ acute bacterial infection & temp 103.6F. Which action should the nurse take? a) obtain a wound culture 30 min after initiating IV antibiotics b) place a fan on the lowest setting in client's room c) apply a cooling blanket directly on the client's skin d) set the room temp at 72F ANSWER d) set the room temp at 72F - promotes a reduction in fever w/o causing shivering. avoid applying a cooling blanket directly on client's skin d/t risk of injury to the skin. place a bath blanket between cooling blanket and client's skin avoid using fan in client room; it promotes dispersal of pathogens in the car and cause client to shiver wound culture should be obtained prior to starting IV abx. Q. Nurse is assessing a school-aged child with DM and BG of 250 mg/dL. Which of the following finding should the nurse expect? a) hyperreflexia b) fruity breath odor c) sweating d) shallow respirations ANSWER b) fruity breath odor + lethargy, thirst & confusion high BG = diminished reflexes, dry skin/mucus membranes, deep/rapid respirations low BG = sweating & shallow respirations Q. Nurse teaching client with scabies and new Rx for Lindane lotion. Which statement indicates understanding of treatment for this parasitic infection? a) I will apply lotion once a day for 1 week. b) I will rub lotion thoroughly from my face to my toes. c) I will wash lotion off 12 hrs after I apply it. d) I should avoid bathing for 6 hrs prior to applying lotion. ANSWER c) I will wash lotion off 12 hrs after I apply it. Lindane should only be used once; reapply 2nd application one week after 1st application if live mites are still present Apply thin film from neck down Bathe/dry skin well/allow to cool before applying lotion Q. Nurse is planning care to prevent hospital-acquired MRSA infection for a client who is immunocompromised. Which intervention should the nurse include to prevent this abx-resistant infection? ANSWER bathe with Hibiclens wipes Q. Client on morphine via PCA pump for post-op pain. HR 66. RR 9. Which medication should provider prescribe? ANSWER Naloxone 1st action nurse should take when using the ABC approach for client who has respiratory acidosis is to improve client's oxygenation (priority) Meds that help with resp acidosis are anti-inflammatory, bronchodilator, and mucolytic (not priority). Check nail beds and oral membranes for appearance of cyanosis (not priority). Ensure adequate optimal hydration to keep mucous membranes moist and to facilitate removal of pulmonary secretions (not priortiy) Q. A nurse in ED was caring for a teen who died following a MVA. Which of the following reactions should the nurse expect the client's 10 y/o sibling to exhibit? ANSWER - sibling believes the client will wake up in a few hrs - sibling is curious about what will happen to client's body - sibling will continue to treat client as though he were still there -sibling will alienate themselves from her family and friends - sibling is curious about what will happen to client's body & what will occur during funeral or memorial services a preschooler may believe that death is temporary or a type of sleep that is reversible. a 10 y/o should have an understanding of the permanence of death. a toddler would act as though the client is still alive due to an inability to separate real life from fantasy a teen who has a terminal illness would alienate themselves from parents & peers. this can cause the teen to feel alone in their struggle to accept the finality of death. Q. A nurse is reviewing the lab report of a client who is taking Exenatide (Byetta) to treat T2DM. Nurse should recognize which lab result is an indication of an adverse reaction to the med? ANSWER HbA1c 6.8% Hct 45% Creatinine 0.9 mg/dL Lipase 185 units/L Lipase 185 units/L - elevated lipase is an indication of pancreatitis, which can indicate the client is experiencing and adverse effect of Exenatide. Physical manifestations of pancreatitis include ongoing, severe abd pain & vomiting. Renal failure is an adverse effect of Exenatide. other lab values are WNL HCT 42-52% men HCT 37-47% females A nurse is assessing a client with K+ level of 2.6 & receiving KCL IV. Which finding should the nurse identify as an indication that the K+ infusion has brought the client's K+ level back to the expected reference range? -ECG shows inverted T waves -Bowel sounds become hyperactive -Hand grasp becomes stronger -SBP is within 30 mm Hg of her SBP hand grasp becomes stronger - hypokalemia can cause a decrease of skeletal muscle strength. An improvement indicates KCL infusion is correcting this electrolyte imbalance. Hypokalemia reduces smooth muscle contractions in GI tract and develops hypoactive bowel sounds and constipation. BS should normalize w/correction of low K+ level, but hyperactivity indicates overcorrection, and, therefore, hyperkalemia. Nurse caring for a school-age child admitted to ED for acute asthma exacerbation. Which action should nurse take first? - encourage child to take frequent sips of cool fluids - apply humidified oxygen with a simple mask - start a peripheral IV - administer an albuterol nebulizer treatment - apply humidified oxygen with a simple mask all the other options also apply but oxygen is the priority Client with diarrhea and vomiting and Na+ level of 124. Which manifestation should the nurse expect? -orthostatic hypotension -hoarse voice -neck vein distention -muscle twitching -orthostatic hypotension; Na+ expected reference range 136-145. Other manifestations of hyponatremia include decreased deep tendon reflexes, headache, confusion & lethargy. muscle twitching is a manifestation of hypernatremia A nurse is conducting a visual assessment for a client who is at risk for developing glaucoma? Which of the following finding should the nurse identify as a risk factor for this condition? -heredity -gender -anemia -hypoglycemia -heredity; other risk factors include aging, central retinal vein occlusion, HTN, DM, retinal detachment and severe myopia the other options are not risk factors for the development of glaucoma A nurse is providing teaching about foot care to a client who has DM. Which of the following statements indicates an understanding of the teaching? -I'll wash my feet every day with soap and lukewarm water. -I'll apply lotion to my feet daily, especially in between my toes. -It's okay for me to go barefoot in the house, but not outside. _I'll soak my feet every evening before bedtime. -I'll wash my feet every day with soap and lukewarm water. A nurse is assessing a client for manifestations of GERD. Which of the following findings indicates tot he nurse that the client might have GERD? -decreased salivation -diarrhea -tonsillitis -globus - globus; a feeling something being in the back of the throat other manifestations of GERD are hypersalivation or water brash; gen abd pain and flatulence; pharyngitis, coughing, hoarseness and wheezing at night not tonsillitis, not diarrhea and not decreased salivation A nurse in a provider's office is reviewing the medical record of client with COPD. Which of the following findings is the priority for the nurse to report to the provider? -CXR results show increased lung space -sputum culture shows gram positive bacteria -SpO2 level is 88% -wt loss of 3 lbs since prior visit -sputum culture shows gram positive bacteria the other options are nonurgent because they are expected findings for COPD client COPD can cause anorexia, fatigue & increased metabolism from dyspnea A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching? -Keep your mouth open when sneezing -Block one nostril when blowing your nose -Use an ear wick candle to remove excess cerumen from the canal -Lubricate cotton-tipped applicators with mineral oil to clean the ear canal Keep your mouth open when sneezing The nurse should instruct the client to keep the mouth open while sneezing to reduce the pressure in the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear drum. A nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as part of the second stage of the grieving process? -loss of self-esteem -chronic physical manifestations -feeling anger toward family members -persistent feelings of hopelessness Feeling anger toward family members - can be anger towards herself, her partner, and others other options are an indication that the client has developed a depressive disorder A nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client care? -client is worried about financially supporting his family because of his illness -client reports pain immediately following P.T. -client reports coughing and a change of voice whenever he eats -client requests to see a priest for spiritual guidance client reports coughing and a change of voice whenever he eats - using Maslow's hierarchy of needs, nurse should determine that the priority finding is client's physiological needs. This findings indicate risk for aspiration; creates an impairment of nutrition. These are physiological needs. The other options are important, but not the priority. A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? -Increased urination -Sweating -Dizziness -Loose stools Increased urination The nurse should expect the client to exhibit manifestations of hyperglycemia, including increased thirst, nausea, vomiting, increased urination, flushed dry skin, acetone breath odor, and a weak, rapid pulse. A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? -fever -abdominal ascites -anxious -nasogastric suctioning A client who has abdominal ascites The nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis. A nurse is assessing a client for manifestations of GERD. Which of the following findings indicates to the nurse that the client might have GERD? -Decreased salivation -Diarrhea -Tonsillitis -Globus Globus The client who has manifestations of GERD will have globus, which is a feeling of something being in the back of the throat. A nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect? Tall T-waves A nurse a reviewing the laboratory report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect? Aspartate aminotransferase (AST) 45 units/L The nurse is providing discharge teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching? -"Use bisacodyl suppositories to stimulate a bowel movement" -"Avoid lifting objects greater than 50 pounds" -"Consume a clear liquid diet until symptoms resolve" -"Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent antibiotic-related diarrhea" "Consume a clear liquid diet until symptoms resolve" The nurse should recommend the client consume a clear liquid diet until manifestations such as abdominal pain, nausea, and vomiting have resolved. A clear liquid diet is low in fiber and does not stimulate intestinal motility. A nurse is providing teaching to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) skin infection. Which of the following client statements indicates an understanding of the management of antibiotic resistant infections? -I will keep the infected area open to air to help it heal -I can sleep in the same bed as my partner after I have been taking antibiotics for 24 hours -I should sit on upholstered chairs instead of hardback chairs -I will wash all uninfected skin areas with a fresh washcloth I will wash all uninfected skin areas with a fresh washcloth The nurse should instruct the client to wash the uninfected skin areas with a fresh washcloth to prevent contamination of the unaffected areas of the skin with the MRSA infection. A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? -fever -abdominal ascites -anxious -nasogastric suctioning A client who has abdominal ascites The nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis. A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? -LDL 168 mg/dL -HDL 50 mg/dL -Total cholesterol 268 mg/dL -Triglycerides 250 mg/dL HDL 50 mg/dL This finding indicates that the client has achieved a therapeutic response from a lifestyle change because the HDL is within the expected reference range of greater than 45 mg/dL for an adult male client. A nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching? I will wash my hands whenever I come home from the grocery store A nurse is providing teaching for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching? I should limit wearing the same shoes 2 days in a row A nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect? Cold intolerance A nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take? Initiate droplet precautions for the infant A nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complications of diabetes mellitus. Which of the following findings should the nurse expect? Hypotension A nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect? Cold intolerance A nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take? Start IV fluid replacement A nurse is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include? Do not bathe your newborn immediately after she eats A nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate? One hand on gait belt walking behind the patient on affected side (right side) A nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include? File your toenails straight across to prevent ingrown toenails A nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which is the following actions should the nurse include? Bathe, diaper, and dress the child before bringing the newborn to the client A nurse is assessing a school-age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority? Inaudible lung sounds A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider? Report of urinating small amounts twice daily A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make? Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite? Place the affected areas of frostbite in a warm water bath A nurse is assessing a client who has developed Clostridium difficile as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe to treat the C. difficile? Vancomycin A nurse is assessing a client in the triage room of an emergency department. Based on the client findings, which of the following actions should the nurse take? Place a surgical mask on the client A nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan? Elevate the client's arm above the heart A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect? Capillary refill greater than 2 seconds A nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect? Potassium 3 mEq/L A nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record? Acrophobia A nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer? Escitalopram A nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following manifestations should the nurse expect? nasal flaring A nurse is caring for a school-age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first? Apply humidified oxygen with simple mask A nurse is caring for a client who has deep vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescription should the nurse expect the provider to prescribe? Protamine sulfate A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? Stay with the client until manifestations subside A nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following findings should the nurse identify as a risk factor for this condition? Heredity A nurse is reviewing the medical record of a client who has age-related macular degeneration (AMD). Which of the following findings should the nurse identify as a risk factor for this visual impairment? Hypertension A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching? I should avoid using the vacuum cleaner for several weeks A nurse is caring for a client who has severe hypothermia. Which of the following actions should the nurse take? Contact a specialized team to place the client on cardiopulmonary bypass A nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect? Oliguria A nurse is assessing a client who is receiving intravenous medications. Which of the following findings should the nurse identify as a manifestation of respiratory acidosis? Confusion A nurse is providing teaching to a client who has osteoporosis. Which of the following information should the nurse include in the teaching? perform exercises to strengthen the abdominal core A nurse is providing dietary teaching to a client who is at 13 weeks gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make? drink fluids between, rather than with, meals A nurse in a provider's office is assessing a client who is taking warfarin to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider? Black, tarry stools A nurse is preparing to administer medication to a client who has a history of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy? Hydrochlorothiazide A nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client's adaptive use of suppression? I avoid thinking about problems that worry me until I have time to focus on a solution A nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching? Long-term use of NSAIDs A nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 min but still has emesis and diarrhea. Which of the following medications should the nurse anticipate administering to the toddler? Ondansetron A nurse is assessing a client whose parents recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving? The client lost his house in a house fire 1 month ago A nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client need? The client reports coughing and a change of voice whenever he eats A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include? Give a second injection if the first fails to reverse your child's symptoms A nurse is reviewing the laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider? Creatinine 2.5 mg/dL A nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect? Bradycardia A hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make? What are some of the best times with your partner that you remember? A nurse is teaching about clonazepam with a young adult female client who has generalized anxiety disorder. Which of the following statements should the nurse include in the teaching? This medication could cause you to have thoughts of self-harm A home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first? place the client in high-Fowler's position A nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child's fever. Which of the following responses should the nurse make? Avoid giving aspirin to your child A nurse on a pediatric unit is preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include? Congenital heart disease A nurse is providing discharge teaching for a client who has a new diagnosis of COPD. Which of the following client statements indicates an understanding of the teaching? I will breathe out slowly through pursed lips if I feel short of breath A nurse is assessing a client who has musculoskeletal trauma following a motor-vehicle crash 2 days ago. Which of the following findings should the nurse report to the provider? Pain report A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? I'll wash my feet everyday with soap and lukewarm water A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions should the nurse take first? Ensure a patent airway using a chin-lift maneuver A nurse a reviewing the laboratory report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect? Aspartate aminotransferase (AST) 45 units/L A nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend as the best source of potassium? One small orange A nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching? Limit the amount of spinach in your diet A nurse is assessing a client who has deep-vein thrombosis (DVT) in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect? Swelling A nurse in an emergency department is reviewing the laboratory report of a client who has hyperventilation. The client's ABG results are pH 7.50, PaCO2 29 mmHg, and HCO3 25 mEq/L. The nurse should interpret that these values are an indication of which of the following acid-base imbalances? Respiratory alkalosis A nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect? Select all that apply Abdominal distention, vomiting, hyperactive bowel sounds